Psychopharmacology in autism: Fifteen Years of Progress, Long Way to Go

Lawrence Scahill, MSN, PhDProfessor of Nursing & Child Psychiatry

Director of the Research Unit on Pediatric Psychopharmacology

Yale Child Study Center

Disclosures• Consultant

- Biomarin- Roche - Bracket

• Research Funding- NIMH, NICHD- Shire Pharmaceuticals- Roche Pharmaceuticals- Pfizer- Tourette Syndrome Association

NIH Multisite Trials in Children with ASDs past 14 yearsStudy N Target Ages Date Published

Risperidone vs placebo

101 Irritability 5-17 2002 NEJM

Methylphenidate vs placebo

66 Hyperactivity 5-14 2005 Arch Gen Psych

Citalopram vs placebo

149 Repetitive Behavior

5-17 2009 Arch Gen Psych

Risperidone vsRIS + Parent Training

124 Irritability & Adaptive Behavior

4.5-13

2009, 2012

J Am Acad Child Psych

Parent Training vs Parent Education

180 Irritability & Adaptive Behavior

3-7 In process

Guanfacine vs placebo

112 Hyperactivity 5-14 In process

Psychopharmacology in ASDs

Outline• Goal of Clinical Research• Definition of ASD• Modern sociology of autism • Psychopharm Scorecards • Two Risperidone Trials • Future Directions

Goal of Clinical Research

• Provide guidance to clinicians on the selection and staging of treatment interventions

• Identify the probability that a given treatment will benefit patients with specific characteristics

• Identify the magnitude of change, the time to effect and the risk/benefit ratio

What Every Mother Wants to Know

If my child starts this medicine:• What are the chances that it will work?• If it works, how much will it help?• How long will it take to ‘kick in?’• How long will my child have to stay on the

medicine?• What are the short- and long-term side

effects?

Autism Spectrum Disorders (ASDs)

• Autism• Asperger’s Disorder• Pervasive Developmental Disorder-Not

Otherwise Specified (PDD-NOS)

Autism Spectrum Disorders (ASD)

• Early onset (before 30 months of age)• Delayed social interaction• Delayed & deviant communication

(not in Asperger’s)• Repetitive behaviors & restricted interests

(stereotypy, fans and air conditioners, British royalty)

DSM-IV Differential diagnosis: Plain & Simple

ASD Social Language Repetitive Type Delay Delay Behavior* Autism Yes Yes Yes

Asperger’s Yes No Yes

PDD-NOS Yes Maybe Maybe

* or Restrictive Interests (preoccupied with train schedules, fans, air conditioners, horses)

ASDs: Other Essential Features • 4:1 male to female• 30% to 70% Mentally Retarded • Impaired daily living skills (not explained by MR)• 25% have seizures • High rates of serious behavioral problems,

hyperactivity and anxiety

Prevalence: How Common are ASDs?• Historically

- Autism 2 to 5 cases per 10,000 • Current

- Autism: 20 per 10,000 - ASDs: 110 per 10,000

• Is there a true rise in the frequency of ASDs?

Center for Disease Control, 2012*****

≈ 550,000 school-age

children

Prevalence is all about counting cases

• Counting all cases (rarely achieved)• Clinically-referred cases

– subset of all cases (invariably underestimates prevalence)

• Community surveys– Necessary, but costly and not easy

prevalence is always an estimate!)

Reasons for Increasing Prevalence

• Broadening of diagnostic rules• Better population sampling • Better diagnostic methods (especially

among lower IQ and higher IQ children)

Sociology of Autism

• Refrigerator mothers• Rising Prevalence• Secretin• Vaccines• Andrew Wakefield• Doug Flutie

Lancet retracts ‘utterly false’ MMR paper guardian.co.uk 2/2/2010

Andrew Wakefield, 1998 paper in Lancet – retracted

due to misconduct

www.dougflutiejrfoundation.com

Reduced stigma (Doug Flutie factor)

The ABCDs of DSM-V

• A: Deficits in social communication and social interaction (blends social with communication)

• B: Restricted, repetitive patterns of behavior (includes insistence on sameness)

• C: Symptoms are present in early childhood• D: Symptoms impair everyday functioning

www.dsm5.org/ProposedRevisions

Target of Medication

• Core Features of Autism– Social Interaction– Repetitive Behavior/Restricted Interests – Impaired Communication

• Specific Behavioral Problems– Hyperactivity– Tantrums, Aggression, Self-injury– Anxiety

Drugs Used in ASD

• Haloperidol• Fenfluramine • Clonidine • Guanfacine

• Naltrexone • Propranolol • Stimulants

• Clomipramine, SSRIs • Atomoxetine • Secretin• Amantadine, memantine • Oxytocin• Anticonvulsants• Atypical antipsychotics

Drug trials in ASD with sample size > 60 subjects Drug target Resultsfenfluramine Social interaction Act=Plasecretin Social Interaction A=Prisperidone Tantrums/aggression A > P +++aripiprazole Tantrums/aggression A > P ++methylphenidate Hyperactivity A > P +citalopram Repetitive behavior A=Pfluoxetine Repetitive behavior A=P+ = small effect; ++ = medium; +++ = large

Most Common Drug Classes in ASD

• SSRIs• Atypical Antipsychotics*• Stimulants

* risperidone & aripiprazole are FDA-approved for children with autism and irritability

SSRIs in Children with ASDsTarget Repetitive

BehaviorRigidity (Trouble with Transitions)

Anxiety Irritability

Rationale Effective for OCD (repetitive behavior)

Need for sameness (? obsessional or anxiety)

Effective in anxiety disorders

? Mood/ Anxiety over-reaction in everyday living situations

Treatment of Repetitive Behavior in ASDs

PlaceboDrug open controlled N > 60Fluoxetine X X XFluvoxamineX XCitalopram X X XSertraline XEscitalopramXClomipramine* X X Not commonly used in ASDs

Serotonin System

Nolte & Angevine, 1995

Neuropharm “a specialty pharmaceutical group focused on the development of drugs for the treatment and management of selected developmental and degenerative disorders.”

www.stockopedia.co.uk/share-prices/neuropharm-LON:NPH/

www.fiercebiotech.com/story/neuropharm-shares-tank-phase

-iii-failure/2009-02-18“NPL-2008 failed to demonstrate a significant reduction in repetitive behavior in autistic pateints when compared to placebo. A totral of 158 pateits, aged between 5 and 17, were enrolled into the SOFIA study in which patient received either NPL-2008 or placebo during a 14-week treatment period.”

STAART Consortium: Citalopram in PDD

• RCT in 149 subjects with PDD (Age 5 to 17)• Citalopram (n=73) or placebo (n=76) 12 Weeks• Primary outcomes Clinical Global Impression -

Improvement and a clinician measure of repetitive behavior (CYBOCS-PDD).

King et al., STAART Group (2009) Arch Gen Psych

Citalopram vs Placebo (N=149)

1 = Very Much Improved2 = Much Improved3 = Minimally Improved4 = No Change5 = Minimally Worse6 = Much Worse7 = Very Much Worse

Clinical Global Impression-Improvement

0 %

1 0 %

2 0 %

30%

4 0 %

5 0 %

6 0 %

7 0 %

8 0 %

9 0 %

0 2 4 6 8 1 0 1 2

Muc

h Im

prov

ed o

r Ver

y M

uch

Impr

oved

P l a c e b o

C it a l o p r a m

Week

p = 0·94

Much Improved or Very Much Improved on (CGI-I) over 12-Week

N=149

p=0.94

Citalopram vs Placebo: Adverse Events*

Adverse Event CITAL PLAN (%) N (%)

energy 28 (38.4%) 15 (19.7%)- initial insomnia 17 (23.3%) 7 (9.2%)impulsiveness14 (19.2%) 5 (6.6%)↓ concentration 9 (12.3%) 2 (2.6%) Hyperactivity 9 (12.3%) 2 (2.6%) Stereotypy 8 (11.0%) 1 (1.3%) Diarrhea 19 (26.0%) 9 (11.8%) initial insomnia 17 (23.3%) 7 (9.2%)

* < .05; King et al., STAART Group (2009) Arch Gen Psych

Conclusions: SSRIs in Children with ASDs

Evidence Repetitive Behavior

Anxiety Rigidity (trouble with Transitions)

Irritability

Placebo-controlled

yes no nono?

open yes yes yes yes

Treatment of Hyperactivity in Children with ASDs

Hyperactivity in ASD: Brief Background

• DSM-IV - don’t diagnose ADHD in children with ASD

• Hyperactivity, disruptive behavior, and impulsiveness are common in children with ASD

• Community surveys show that stimulants are commonly used in children with ASD

• Evidence was limited

Treatment of Hyperactivity in PDD

Drug open controlled N > 60Methylphenidate X XAtomoxetineX XClonidine X XGuanfacine X XAmantadine X XNaltrexone X X

RUPP TrialMPH > PLA

Effect size: small to medium

RUPP Autism Network: Methylphenidate in Children

With PDD + Hyperactivity

RUPP = Research Unit on Pediatric Psychopharmacology

RUPP Autism Network. Arch Gen Psych 2005;62(11):1266-74

Dopamine System

Nolte & Angevine, 1995

MPH in Children With PDD + Hyperactivity: Subject Characteristics in Crossover

• Sample N=66 (59 boys, 7 girls) • Mean age = 7.5 2.2 years (range 5.0-13.7)• Mean IQ = 63 33• Autism = 56• Three doses of MPH and placebo in random order

RUPP Autism Network. Arch Gen Psych. 2005;62(11):1266-74

MPH Improvement on Teacher Rating of ADHD symptoms

Dose Level % Change*

RUPP Low 12%RUPP Medium 13%RUPP High 17%

* Corrected for Placebo

In ADHD ≈ 40% over placebo

MPH in PDD: Conclusions1) At low doses (12.5-25 mg/day), the

medicine helps about 50-60% of children.2) At low doses, it will produce about 20%

improvement3) At low doses, it will be well-tolerated4) Higher doses are unlikely to bring about

additional benefit and may risk of adverse effects

Treatment of Serious Behavioral Problems in Children with ASDs

Atypical Antipsychotics in ASDPlacebo

Drug open controlled N > 60

Risperidone* X X XOlanzapine XZiprasidone X Quetiapine XAripiprazole* X X X

* FDA Approved for Rx of ‘irritability’ in autism

DA Synapse

Research Units on Pediatric Psychopharmacology Autism

NetworkRisperidone Trials

RUPP Risperidone: Sample

• N=101 (82 males, 19 females)– Risperidone: N=49– Placebo: N=52

• 8-week, randomized, double-blind, placebo-controlled, parallel groups

• Mean age = 8.8 years (range 5-17)

RUPP Autism Network. NEJM, 347(5): 314-321.

ABC Irritability Scores at Baseline and End Point by Treatment Group

Risperidone Placebo

ABC Baseline End Point Baseline End PointScale Mean (SD) Mean (SD) Mean (SD) Mean (SD) Irritability 26.2 (7.9) 11.3 (7.4) 25.5 (6.6) 21.9 (9.5)

p<0.0001; Effect Size = 1.3; RUPP Autism Network. NEJM, 347(5): 314-321.

Mean Dose=1.8 mg/day

RUPP Autism Network: Irritability Scale

RUPP Autism Network. NEJM, 347(5): 314-321.

0

5

10

15

20

25

30

0 2 4 6 8

Week

AB

C Ir

ritab

ility

Tot

al

Risperidone mean

Placebo mean

Mean =1.8 mg/day; ES=1.3

Clinical Global Impression-Improvement

1 = Very Much Improved2 = Much Improved3 = Minimally Improved4 = No Change5 = Minimally Worse6 = Much Worse7 = Very Much Worse

RUPP Autism Network. NEJM, 347(5): 314-321.

Clinical Global Impressions-Improvement

RUPP Autism Network. NEJM, 347(5): 314-321.

0102030405060708090

0 1 2 3 4 5 6 7 8

Week

Perc

enta

ge o

f Par

ticip

ants

with

CG

I-I <

3

Risperidone

Placebo

RUPP Risperidone Study: Adverse Effects

Appetite (Mild) 24 (49.0) 15 (28.8) 0.05

Appetite (Mod) 12 (24.5) 2 (3.8) 0.01

Tiredness 29 (59.2) 14 (26.9) 0.002

Drowsiness 24 (49.0) 6 (11.8) <0.001

Drooling 13 (26.5) 3 (5.8) 0.01

Tremor 7 (14.3) 1 (1.9) 0.05

Mean Weight Gain (kg) 2.7 2.9 0.8 2.2 <0.01

RUPP Autism Network. NEJM, 347(5): 314-321.

RISP (N=49) PLA (N=52)Adverse Effect N (%) N (%) p-Value

Four Month Open label

RUPP Autism Network. Am J Psychiatry. 2005;162(7):1361-9

ABC Irritability Scores by Week in Open-Label (N=63)

RUPP Autism Network. Am J Psychiatry. 2005;162(7):1361-9

05

10152025303540

Week 0 Week 4 Week 8 Week 12 Week 16

Mean Irritability score

Mean Dose in Open-Label Risperidone A

vera

ge m

g/da

y

RUPPP Autism Network. Am J Psychiatry. 2005;162(7):1361-9

00.5

11.5

22.5

33.5

44.5

55.5

6

Week 4 Week 8 Week 12 Week 16

Risperidone dose

Risperidone Extension: Weight Gain

• N=63 followed for 6 months of treatment

• Mean weight gain = 5.6 3.9 kg– No clear predictors of weight gain

• Weight gain greatest in first 2 months– 1.4 kg/month vs. average of 0.88 kg/month

• Monitoring and counseling about diet and weight at the start of treatment

Martin A et al. Am J Psychiatry. 2004;161(6):1125-7

Risperidone in Autism: Conclusions 1) At low to medium doses (1.25 to 1.75 mg/day),

70% of children with autism + tantrums, aggression, self-injury will show positive response.

2) Magnitude of improvement > 50% 3) At low to medium doses, drug is well-tolerated and

benefits endure over time4) Discontinuation at 6 months relapse 5) Weight gain requires monitoring throughout

treatment

RUPP Autism Network:Risperidone only vs.

Risperidone + Parent Training

RUPP Autism Network, JAm Acad Child Adoles Psychiatry, 11/09

Risperidone only vs Risperidone + Parent Training

Design• 6-month study• 124 subjects (age 4 to 13 years) • Random assignment

– risperidone only (N=49) or – risperidone + Parent training (N=75)

Risperidone only vs Risperidone + PT

Study Model: The medication tantrums, aggression and self-injury, setting the stage for PT improve adaptive skills.

↓ noncompliance adaptive skills (can’t do vs won’t do)

Behavior Therapy: Basics• Antecedents & consequences (function of the behavior)• Environmental manipulation (↓ triggering situation) functional communication (teach child to request a break vs acting out to escape demands)

• Extinction (selective ignoring) • Positive reinforcement (go for incremental success)

Sample Characteristics

Variable MED COMB Age 7.5 7.4 Irritability 29.7 (6.10) 29.3 (6.97)Autism 32 (65.3) 49 (65.3) PDD-NOS 13 (26.5) 22 (29.3)Asperger’s 4 (8.2) 4 (5.3)Average IQ 11 (22.5) 28 (38.4)*

*P < .05

Maladaptive Behavior Outcomes

Measure COMB (75)|-- BL--||-- EP--|

MED (N=49)|-- BL-- ||--EP--|

ES

HSQ 4.3(1.67)

1.23(1.36)

4.16 (1.47)

1.68 (1.36)

0.34*

ABC-Irritability

29.3 (6.97)

11.0(6.64)

29.7 (6.10)

14.5 (9.90)

0.48*

* p < .05

Maladaptive Behavior Outcomes

Measure COMB (75)|-- BL--||-- EP--|

MED (N=49)|-- BL--||-- EP--|

ES

ABC-Irritability

29.3 (6.97)

11.0(6.64)

29.7 (6.10)

14.5 (9.90)

0.48*

* p < .05

ABC Irritability

1012141618202224262830

BL Week 8 Week 16 Week 24

HSQ

Sco

re

MEDCOMB

ES = .48

Parent-rated Home Situations Questionnaire Scores

at Baseline Through Week 24 with LSMeans

0

1

2

3

4

5

0 5 10 15 20 25

WEEK

MED

COMB

Mea

n Se

verit

y Sc

ore

E.S. = .34

Adaptive Behavior Outcomes

Vineland Domain

COMB (65)| -- BL--| |-- EP--|

MED (N=42)|-- BL--| |-- EP--|

ES

Daily Living 50.8 (18.49)

55.6 (21.86)

41.1 (19.81)

45.3(20.48)

.13

Socialization 59.5 (15.01)

67.4 (18.48)

53.5 (14.41)

56.6 (17.38)

.35*

Communication 61.2 (20.95)

63.9 (22.65)

53.2 (19.94)

53.6 (20.23)

.15

Adaptive Composite

53.1 (15.66)

57.9(19.03)

45.8 (15.50)

47.8 (15.81)

.22*

* p < .05

RUPP Autism Network, JAm Acad Child Adoles Psychiatry, 02/12

Adaptive Behavior Outcomes

Vineland Domain

COMB (65)| -- BL--| |-- EP--|

MED (N=42)|-- BL--| |-- EP--|

ES

Daily Living 50.8 55.6 41.1 45.3 .13

Socialization 59.5 67.4 53.5 56.6 .35*

Communication 61.2 63.9 53.2 53.6 .15

Adaptive Composite 53.1 57.9 45.8 47.8 .22*

* p < .05

RUPP Autism Network, JAm Acad Child Adoles Psychiatry, 02/12

RIS + PT vs RIS only on Vineland Adaptive Behavior scales

Daily Living Socialization Communication

COMB > MEDNo yes No

Scahill et al., JAm Acad Child Adoles Psychiatry, 02/12

Adaptive Behavior Outcomes

Vineland Domain

COMB (65)| -- BL--| |-- EP--|

MED (N=42)|-- BL--| |-- EP--|

ES

Daily Living 50.8 55.6 41.1 45.3 .13

Socialization 59.5 67.4 53.5 56.6 .35*

Communication 61.2 63.9 53.2 53.6 .15

Adaptive Composite

53.1 57.9 45.8 47.8 .22*

* p < .05

RUPP Autism Network, JAm Acad Child Adoles Psychiatry, 02/12

Vineland (Scahill et al., 2012; JAACAP)

NIH Multisite Trials in Children with ASDs past 15 years

Study N Target Ages ResultsRisperidone vs placebo (2002)

101 Irritability 5-17 RIS > PLA (large effect)

Methylphenidate vs placebo (2005)

66 Hyperactivity

5-14 MPH > PLA (small to medium effect)

Citalopram vs placebo (2009)

149 Repetitive Behavior

5-17 CITALO = PLA

RIS vs RIS + Parent Training (2009, 2012)

124 Irritability & Adaptive Behavior

4.5-13

RIS + PT > RIS alone (small to medium effect)*

* Small to medium effect over large effect of drug alone

Future Directions

• Parent Training as a ‘stand alone’ treatment• Drug selection

- Based on ↑ understanding of neurobiology- Drugs not on the market (industry partnership) - Begin with adults (establish safety) • Needed- Better outcome measures (e.g., social disability, anxiety)

Compounds worthy of study in ASDCompound On

marketTarget Available

measureSSRI Yes Anxiety Not Quite

PregabalinD1 Antagonist No SIB OK

Oxytocin Yes

Social interaction

Yes, but

mGluR antagonist No

mGluR agonist No

Vasopressin R antagonist No

Ready?

Thank you